Common Mental Disorders Depression - New Zealand Doctor

Chapter 5 Recognition and assessment of common mental disorders in adults/pakeke
Identification of any of the following factors should trigger immediate referral
to secondary care mental health services: 65
• serious suicidal intent
• psychotic symptoms
• severe and persistent self-neglect (eg, not eating).
A person with a new episode of bipolar disorder may be managed in primary care if a
management plan can be put in place that has been successful on previous occasions.
However, if new-onset bipolar disorder is suspected, urgent referral to secondary mental
health care is generally recommended. The urgency of a referral in an individual case
is dependent upon the acuity of symptoms. The patient needs active support during the
waiting phase for secondary care mental health services treatment. 9,65
The GDT notes that factors signalling the need to refer urgently to secondary care
mental health services include: 9,65
• perceived significant but not immediate risk of harm to self or others
• treatment resistant depression
• new-onset bipolar disorder.
Further factors, including the following, indicate that referral should be considered:
• recurrent depression if not responsive to past treatments
• atypical depression resistant to initial treatment
• a comorbid medical condition that impacts on antidepressant use
• diagnostic uncertainty.
An adult with mild depression is generally disturbed but able to carry out normal
activities. An adult with moderate depression may have significant difficulty continuing
with normal activities, while an adult with severe depression will have very marked
functional impairment and often has strong feelings of worthlessness and guilt and/
or suicidal thoughts. 327 Accurate assessment of acuity and severity is important for
appropriate management and referral. In addition, using their clinical judgment,
the practitioner should consider the use of a severity-assessment tool. The severity of
symptoms and functional disability can be measured using the PHQ-9. 320 The GDT
notes that the K10 may also be useful for monitoring severity. 325 Details of the thresholds
used to determine severity with the PHQ-9 and K10 are included in Box 5.4: Thresholds
to Determine Severity. Responses to the functionality questions on these tools may be
helpful in triggering discussion of patient priorities and goals for treatment.
Identification of Common Mental Disorders and Management of Depression in Primary Care 65